The scientific road to recovery

By Sandra Gelbard
Two weeks ago, Los Angeles announced that it will be the first city in the country to offer coronavirus testing to all residents — regardless of whether they are in the throes of it or entirely asymptomatic. This stands in sharp contrast to the New York Department of Health order last week precluding physicians from performing viral testing on patients unless they are symptomatic or otherwise met very strict criteria. New York would do well to follow Los Angeles’ lead when it comes to universal testing, as this will give us the clearest understanding of the biology of the coronavirus and provide the data needed to safely reopen society.
As an internal medicine doctor in New York City, I have been treating coronavirus patients since the onset of the pandemic and have lost count of the number of times I have been asked “When will this end? When will we return to normalcy?” My answer has been consistent and simple: one of three things must happen before we can return to normalcy. We must develop a reliable and widely available vaccine, wait for herd immunity or develop an effective cure or treatment. None of these goals will be easy to achieve.
I think it is a tall order to expect a vaccine — that can be widely, safely, and effectively administered — in less than 12 to 18 months. If history is any guide, there is little reason for optimism: developing vaccines for similar viruses like SARS and MERS has proven to be very tricky and, to date, impossible. The reason? A bad vaccine can be more than simply ineffective, it can trigger a dangerous reaction called immune enhancement, which may result in death. Then there is the discussion of herd immunity.
Herd is accomplished when a sufficient number of people in a specific area have both contracted and recovered from the coronavirus, which many scientists and medical practitioners believe confers immunity. With mortality rates originally estimated at 1 percent (albeit now appearing to possibly be at significantly less than that) that translates into a death toll of more than 2 million people, an unfathomable price to pay to achieve herd immunity. In addition, this does not account for the speculation in certain circles that it may be possible to recontract the coronavirus and/or that recovering from the coronavirus may not confer immunity in the first place.
More practically, herd immunity is unlikely to come to pass because most of our nation’s governors opted instead for shelter in place or stay at home orders, as well as social distancing to stop the spread. Make no mistake, this was the right thing to do, and as a result we are now seeing a decrease in the number of hospitalizations and deaths, resulting in a flattening of the curve. This is giving our health care system a much needed opportunity to catch up.
To date, our assumptions about the deadliness of the coronavirus have relied upon the case fatality rate, which is the number of coronavirus deaths divided by the number of those who have tested positive. But we do not have an accurate sense of how many people really have tested positive since only those with severe symptoms were tested.
New York City, like Los Angeles, needs to know how many asymptomatic people are out there in order to understand the true prevalence of the coronavirus and calculate an accurate mortality rate to contain the spread. This will allow us to determine the infection fatality rate, which is the number of coronavirus deaths divided by the total number of symptomatic and asymptomatic people who have contracted the disease.
While New York State has concluded from recent antibody testing that about 12 percent of the population had the coronavirus in the past, this limited antibody testing only offers us a picture of the prevalence of the coronavirus from a month ago and not the incidence of new cases that currently exist. Without this information, we have no way of knowing who is currently infected and therefore cannot determine properly how to prevent further spread once we reopen society.
If we want a more accurate picture, we must perform both viral testing and antibody testing on a systematic basis. This is not just an academic exercise. It is critical to safely reopening society. Reopening without having a handle on the infection fatality rate will lead to a disorganized and potentially devastating, and deadly outcome. But if we execute broad testing on both symptomatic and asymptomatic individuals and find for example that 30 percent or more of the population are asymptomatic carriers, it would mean that the infection fatality rate is not as lethal as we originally thought and would provide scientific reassurance that we can safely reenter society in the near future.
Just as New York gave a glimpse for the rest of the country to see how overwhelming and deadly this disease could be in a large metropolitan setting, we now can lead the way and show other states, and even other countries, how to safely reopen society if we perform both coronavirus testing and antibody testing.
Sandra Gelbard is a board certified internal medicine doctor and clinical instructor at Langone Medical Center and Lenox Hill Hospital in New York City. She is a member of the American Medical Association and American College of Physicians and has been featured in numerous news programs.
– The Hill

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